Acne
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This document summarizes guidelines for treating acne vulgaris. It begins by reviewing the pathogenesis and types of acne. It then outlines a treatment approach including topical retinoids, antibiotics, and oral medications like isotretinoin. Specific recommendations are provided for treating comedonal, papulopustular, and nodulocystic acne. Education on proper application and expected timelines is also covered.
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Acne
- 1. Acne Vulgaris (Otherwise known as zits, pimples and blackheads) www.hi-dentfinishingschool.blogspot.com
Editor's Notes
- Lower incidence in Asians and African-Americans Despite lower incidence in darker skinned people it is important to note that the prevalence of acne-induced scarring and hyperpigmentation is increased in these groups compared light skinned patients. 65% of AA 52% of Latinos 47% Asians
- P. acnes , are present in increased numbers in persons who have acne. Much of the inflammation that eventually occurs arises from the action of enzymes produced by the bacteria. These enzymes hydrolyze sebum into free fatty acids, which stimulate the inflammatory process. Chemotactic factors are released by this reaction, attracting neutrophils. As the follicular wall becomes inflamed, an erythematous papule appears at the skin surface. With increased sebum production, obstruction and bacterial colonization, the follicular unit ruptures, spilling its contents into the dermis. The inflow of neutrophils causes the formation of pustules. Continuation of severe inflammation leads to formation of nodules and subsequent cysts.
- Comedonal acne consists predominantly of open or closed comedones with little or no accompanying inflammation (Figure 2) . This type of acne typically responds to topical keratolytic agents that decrease the cohesiveness of the follicular cells. Erythematous papules and pustules characterize inflammatory acne, but comedones may also be present (Figure 3) . Topical agents alone may be insufficient to treat inflammatory acne, which may benefit from systemic antibiotics. Nodulocystic acne may consist of comedones and inflammatory lesions, as well as deeper nodules and cysts (Figure 4) . Although a six-month course of systemic antibiotics may be effective, nodulocystic acne frequently requires treatment with isotretinoin (Accutane). . Comedonal acne. In closed comedones (whiteheads), a mass of desquamated cells plugs the follicular canal above the opening of the sebaceous gland. Sebum accumulates within the follicular canal and results in a white papule visible at the skin surface. In open comedones (blackheads), when the opening of the follicular canal dilates, the plug protrudes from the canal and turns a dark color.
- Adjuvant therapy with other agents may be considered during isotretinoin treatment. Topical antibiotics may be beneficial, but use of topical keratolytics and drying agents should be discontinued because concomitant use may lead to extensive dryness. Occasionally, oral erythromycin or prednisone is used at the beginning of isotretinoin therapy to control the initial acne flare-up. None of the tetracyclines should be used for this purpose because the combination of a tetracycline and isotretinoin increases the likelihood of pseudotumor cerebri development.20 Pustules generally clear more rapidly than papules or nodules. Lesions on the face, upper arms and legs tend to respond more quickly than those on the trunk. After reaching the goal dosage of 120 to 150 mg per kg, isotretinoin therapy should be discontinued even if the acne is not completely clear because improvement continues for one to two months following cessation of treatment.
- It can be taken with food and, unlike the other tetracyclines, only infrequently causes photosensitivity. Most adverse effects of minocycline are similar to those of the other tetracyclines (Table 3) . However, minocycline may cause cutaneous hyperpigmentation in scars, vertigo and, in rare instances, the development of a lupus-like syndrome